pain and problematic use of opioids society for the study of addiction: york 2014 dr cathy stannard:...
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Pain and problematic use of opioids
Society for the Study of Addiction: York 2014
Dr Cathy Stannard: Bristol
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Session overview
• About pain
• About opioids for pain
• Prescription opioids: harms data• US• UK and Europe
• Pain and opioid treatment: a recipe for disaster?
• Avoiding prescription opioid related harms
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About painPain and problematic use of opioids
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Thoughts about pain relief
• Yes we should try to treat pain but…
• Pain can’t always be treated
• Inability to reduce a patient’s pain intensity is neither a reflection of lack of effort nor a sign of incompetence
• Trying hard to treat pain and making the patient worse is not a result
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Some Risk factors for chronic pain include…
• Mental health diagnoses
• Emotional trauma
• Perceived disability
• Substance misuse disorders (including alcohol)
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About opioids for painPain and problematic use of opioids
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Why are opioids prescribed?
Because…
• they are strong analgesics
• persistent pain is hard to treat so something strong is a tempting idea
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WHO 1986
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WHO 1986
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Why are opioids prescribed?
Because…
• they are strong analgesics
• persistent pain is hard to treat so something strong is a tempting idea
• pain sufferers exhibit distress
• distress makes clinicians want to do something
• we know there are risks but think we can handle them
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14
Strong opioids: Prescription Cost Analysis
20042005
20062007
20082009
20102011
20122013
0
0.5
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1.5
2
2.5
3
3.5
4
Num
ber o
f ite
ms (
mill
ions
)
20042005
20062007
20082009
20102011
20122013
0
10
20
30
40
50
60
70
80
MorphineOxycodoneFentanylBuprenorphine
Cost
(£ m
illio
n)
Items Cost
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Trends in Prescribing of Opioid Analgesics on NHS prescriptions in England
© Copyright NHSBSA 2014
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2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100
5000
10000
15000
20000
25000
30000
35000
40000
45000
50000
Cancer
Non-cancer
Num
ber
of p
atie
nts
Zin CS et al. Eur J Pain 2014.
Number of patients prescribed opioids
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Variation Between Clinical Commissioning Groups in Prescribing of Opioid Analgesics (Quarter to June 2014)
© Copyright NHSBSA 2014
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Variation Between Clinical Commissioning Groups in Prescribing of Fentanyl (BNF 4.7.2)(Quarter to June 2014)
© Copyright NHSBSA 2014
London CCGs
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LO
ND
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Variation Between Strategic Health Authorities in Prescribing of Opioid Analgesics (Quarter to March 2013)
Tramadol Codeine Morphine Dihydrocodeine
Buprenorphine Fentanyl Oxycodone Others 4.7.2
Ite
ms
pe
r 1
00
0 P
ati
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ts
© Copyright NHSBSA 2013
SHA median 92.8
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Variation between Strategic Health Authorities in prescribing of Benzodiazepines (Quarter to March 2010) NHS prescribing services.
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Prescription Opioids harms data
Pain and problematic use of opioids
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Opioid pain reliever (OPR) death rates and sales, U.S., 1999-2010
Source: National Vital Statistics System. Age-adjusted rates per 100,000 population for OPR deaths and crude rates per 10,000 population for kilograms of OPR sold. Some overdose deaths were not included in the total for 2009 because of delayed reporting of the final cause of death. The reported 2009 numbers are underestimates.
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100
1
2
3
4
5
6
7
8
OPR Deaths/100,000 OPR sales kg/10,000
Rate
per
100
,000
15 000 deaths
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Public health impact of opioid pain reliever use
Based on 15,597 OPR overdose deaths in 2009.Treatment admissions are for primary use of opioids from Treatment Exposure Data set for 2009.Emergency department (ED) visits are from DAWN (Drug Abuse Warning Network) for 2009Abuse/dependence and nonmedical use in the past year are from the 2009 National Survey on Drug Use and Health
Past Year Nonmedical users
People with abuse/dependence
ED visits for misuse or abuse
Abuse treatment admissions
For every opioid overdose death in 2009 there were:
30
118
795
9
14-Oct-2014
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0123456789
10
1-19 mg. 20-49 mg. 50-99 mg. 100+ mg.
0
0.5
1
1.5
2
2.5
3
3.5
1-19 mg. 20-49 mg. 50-99 mg. 100-199 mg. 200 + mg.
0
1
2
3
4
5
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7
8
1-19 mg. 20-49 mg. 50-99 mg. 100+ mg.
DEATHS AND HIGH DOSESCrude association of daily dosage of opioid analgesics with risk of unintentional drug overdose death, New Mexico, October, 2006—March, 2008
Paulozzi , et al. Pain Med 2012; 13:87-95Dunn et al., Annals Int Med, 2010
Gomes et al., Arch Int Med, 2011 Bohnert et al., JAMA, 2011
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2 955 drug related deaths ↑ 765 heroin/morphine ↑
429 methadone ↑
232 codeine, DHC ↓
220 tramadol ↑ ↑
Deaths related to drug poisoning/misuseEngland and Wales 2013
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Figure 7: POM/OTC compounds identified as being problematic byindividuals new to drug treatment who report other illegal drug use(2005-06 to 2009-10). NTA 2011
Population 56.1m
(16% population in treatment)
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Figure 6: POM/OTC compounds identified as being problematic byindividuals new to drug treatment services who do not report problems with other illegal drug use (2005-06 to 2009-10).NTA 2011
Population 56.1m
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NDTMS personal communication
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Pain and opioid treatment
a recipe for disaster?
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Risks of running into problems with high dose opioids
• Patient factors• Depression/common mental health diagnoses • Alcohol misuse/non-opioid drug misuse• Opioid misuse
• Drug factors• High doses• Multiple opioids• More potent drugs• Concurrent benzodiazepines/sedative drugs
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Who gets long term opioid therapy?Increased risk includes:
• Patient factors• Depression/common mental health diagnoses (x3-4)• Alcohol misuse/non-opioid drug misuse (x4-5)• Opioid misuse (x5-10)
and
• At risk patients are more likely to receive• High doses• Multiple opioids• More potent drugs• Concurrent benzodiazepines/sedative drugs
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Discontinuation of opioids
• N = 550 616
• Fewer than 20% discontinued at 3.5 years
• Factors associated with discontinuation• High doses • Young or old age • Tobacco consumption • Mental health disorders and substance misuse
disorders
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Avoiding prescription opioid related harms
Pain and problematic use of opioids
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Sensible prescribing
• Recognition of public concerns and ability to contextualise these
• Awareness of literature on effectiveness and harms
• Comprehensive evaluation and formulation of patient problems
• Practice always underpinned by evidence
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Sensible prescribing
• Recognition of public concerns and ability to contextualise these
• Awareness of literature on effectiveness and harms
• Comprehensive evaluation and formulation of patient problems
• Practice always underpinned by evidence
• Safest• Old• Low dose• Intermittent
PERSONAL ANECDOTE
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Iatrogenesis
Sullivan and Howe Pain 154 (2013) S94-100
“By becoming unnecessary, pain has become unbearable. With thisattitude, it now seems rational to flee pain rather than to faceit, even at the cost of addiction. It also seems reasonable toeliminate pain, even at the cost of health…
…For a while it can be argued that the total painanaesthetised in a society is greater than the totality of painnewly generated. But at some point, rising marginaldisutilities set in. The new suffering is not only unmanageable,but it has lost its referential character. It has becomemeaningless, questionless torture. Only the recovery of thewill and ability to suffer can restore health into pain.”
Reproduced in J Epidemiol Community Health 2003;57:919-922 doi:10.1136/jech.57.12.919
Ivan Illich Medical Nemesis